The Clinical Method
in Family Medicine
Introduction to Primary Care:
a course of the Center of Post Graduate Studies in FM
PO Box 27121 – Riyadh 11417
Tel: 4912326 – Fax: 4970847
Aims-Objectives
• Aim: the participants will have knowledge on the
patient centered clinical method.
• Objectives: be able to
– state Levenstein’s patient centered
clinical method principles
– discuss the diagnostic process in family
practice
– describe the common errors done during
a diagnostic process
– discuss how time can be used as a
diagnostic tool in general practice
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What are the methods
physician used to solve
problems?
McWhinney, 1997
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Pattern recognition
• e.g. Childhood eczema
• a distinctive appearance and distribution, affecting
mainly the flexures of the wrists, the elbows and the
backs of the knees.
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Algorithms
• Clinical reasoning that proceeds
systematically through branching decision
points
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Algorithms
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Inductive reasoning methods
 Chief Complaint
 History of The Present Complaint
 Past Medical History
 Family History
 Personal & Social History
Drug & Allergy History Systems Review
Physical Examination
Biological Diagnosis
Disease Management:
Investigation
Prescribing
Follow-up Appoint
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• Doctors – centered (concentrate on
doctors –agenda)
• Biomedical approach (aims to diagnose or
exclude organic disease
• Managing a specific disease
• What else?
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Hypothetical deductive reasoning
method
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Hypothetical deductive reasoning method
• e.g. a patient presents with a fever
productive cough and decreased appetite.
• The hypothesis :
– pneumonia,
– bronchitis or
– an upper respiratory infection (URI).
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We collect some data to help us confirm or reject our
hypothesis. The data tell us that our patient has high
temperature and some rhonchi at the right base on
auscultation.
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• We decide that’s not quite enough information
on which to base a decision, so we also order a
chest X-ray. It shows a right lower lobe
infiltrate. We’re then able to confirm our
diagnosis of pneumonia.
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The diagnostic process
Clues
Hypothesis
Review
Unexpected clues
Investigation
Finding commmon ground
Management decision
Follow up
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Relative contributions to the diagnosis
• In medical OPD:
– history alone determine the diagnosis
in 56 % of all referral made (2756%)
– Physical examination : 17 % (0-24%)
– Routine investigation: 5% (0-17%)
– Special investigations: 18% (6-58%)
– Routine CBC & urinalysis: 1%
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Generating and ranking appropriate
diagnostic possibilities
• Probability: (the most likely)
• Seriousness: (the average GP is likely to encounter a
malignant melanoma only once or twice in a
professional lifetime, so suspicion should be genius.
• Treatability: hypothyroidism is an uncommon cause of
tiredness but it should not be overlooked as it is readily
corrected by replacement therapy
• Novelty: e.g pheochromocytoma as a cause of
hypertension
• 5 : 2 ratio (most likely: less likely but important to
consider)
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How can we apply this method
in family practice?
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Levenstein’s model, McWhinney 1984
The Disease - Illness Model
Patient Presents Problem (s)
Gathering Information
Parallel search of two frameworks
Disease Framework
Illness Framework
The Doctors Agenda
The Patients Agenda
Symptoms
Ideas
Signs
Concerns
Investigations
Expectations
Pathology
Feelings
Thoughts the patient’s unique
Understanding
experience
of their problem(s)
Effects
Differential Diagnosis
Integrating the two
frameworks
Explanation & planning
Reaching a shared understanding
& decision-making
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Levenstein’s model (1984)
1. Evaluating both the disease
and the illness experience
– Differential diagnosis
– Extent of disease
(effect on the feelings, expectations,
ideas and functions of the patient)
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Disease
Illness
“Differentiated”
“Unique personal experience”
• Signs and symptoms
• Feelings
• Abnormal tests
• Expectations
• A “classification”
• Fuctions…
• Illness is a personal perception
Doctor waves back and forth
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Example: increased cholesterol
• Disease
– CAD, past MI
– Obesity
– Hypercholesterole
mia
– Rule out
depresssion
• Illness
– Ideas: no longer a healthy
man
– Feelings: fear of inability to
participate family activities or
even a second MI
– Expectations: co-operation
with doctor regarding diet
– Functions: walks 6 km per
day. Returned to work. Sexual
activity needs to be explored
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2. Understanding the whole person
–
–
“as a person” (life story, personal and
developmental conditions)
Context (anybody being effected from the
patients condition, physical environment)
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Disease
Person
Illness
Environment
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3. Finding common ground with
the patient about the problem
and its management
–
–
–
Problems and priorities
Treatment goals
Roles of doctor and patient in the treatment
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4. Incorporating prevention and health
promotion
–
–
–
–
Health promotion
Risk reduction
Early diagnosis
Decreasing complications
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5. Enhancing the doctor-patient
relationship
–
–
–
–
–
Features of the therapeutic relationship
Sharing of power
Care and cure
Self awareness
Transference and countertransference
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6. Being realistic
–
–
–
Time
Resources
Team
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Mr. Farouk, a 36-years old bank manager, come to see
you. He has been a practice patient for 3 years. You
have seen him only once for a routine health check 6
month previously when no problems were identified. He
asked to see you urgently today. He like worried and tells
you that while driving to an appointment earlier today he
developed a pain in his neck, which spread to his back and
chest. The pains have persisted and he has now developed
“tingling” in his hands and face.
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Q1. What are your initial hypotheses? Explain why you
arrived at these?
Most likely hypotheses:
Less likely hypotheses:
Q2. What questions you want to ask to test your
hypotheses?
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You learn that Mr. Farouk has been under a great deal of
stress at work. He is working a continuous 10-hour/day and
then taking work home. The pain has started gradually some
2 hours previously when he was on his way to an important
customer who was threatening to transfer his account. He is
worried that he has had a heart attack. There are no other
positive features in the history.
Q3. What is your hypothesis now? How did you arrive at
these?
Most likely hypotheses:
Less likely hypotheses:
Q4. What physical exam you are going to perform?
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Mr. Farouk was obviously anxious during the interview but
relaxed during the examination. His pain and tingling have
now gone. You have found no specific abnormality on
examination.
Q5 What is your management?
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Common errors in diagnostic process
• Unwarranted fixation on a hypothesis:
twisting all data in an attempt to fit it)
• Premature closure of hypothesis generation
• Rule-out syndrome: (due to poorly focused
history-taking)
• Generation of very unlikely hypothesis
(novelty)
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Use of time as a diagnostic aid
 Wait and see approach
 About 72 % of patients who had originally been
undiagnosed did not need to return to their doctor
mainly because of spontaneous remission of symptoms
 The doctor must be able to control in himself and in his
patient the almost inevitable feelings of uncertainty
 Use safety net properly
 It allows doctor to have a course between the ‘overreaction’ and the “under-reaction”
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By using time as a diagnostic strategy, the
following problems can be avoided:
• Devoting too much time to minor or self-limiting
conditions
• Unnecessarily subjecting his patients to
inconvenient, painful or costly investigations
• Increasing his patient’s anxiety
• Referring to other specialties too frequently or
with an inappropriate degree of urgency
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